Background
Methods
Ethical considerations
Aims
Design
Participants
Procedure
Phase 1
Phase 2
Phase 3
Phase 4
Results
Phase 1
Physical activity participation | Enabling factors | Perceived barrier | Perceived enabler | |
Limited PA facilities available locally | Community activities facilitated by private clubs (Thai boxing, football, dance, table tennis, gymnastics) and/or local authorities. | |||
“A few more different clubs that do different sports that are around, because there isn’t many.” (P4, pg7, lines 306–307).
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The swimming centre up the road, and out there is a big Astro Turf…so I’ll usually go there, and the other places are sports clubs and stuff.” (P2, pg7, lines 301–302).
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Limited time available to introduce and explore new activities | Curricular physical education (PE) and additional non-structured activities such as walking to and from school and play during recess. | |||
“Maybe if I’d seen a game or something on the telly, or one of my mates was going to somewhere and said that “it’s good”. “You should come and try it”. I might have a go, but I probably wouldn’t, because I don’t really have time…” (P7, pg10, lines 431–440).
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“I don’t do any out of school, but in school, apart from PE I do football at breaks and dinners.” (P3, pg3, lines 120–121).
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Autonomy promoted by independent travel | ||||
“I can do it [travel] on my own. It’s like I’m not dependent on everyone else to do it for me.” (P7, pg9, lines 361–362).
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“It’s either a lift or, because it’s across the [name of local] field across the road, so I can just walk over to that…” (P6, pg8, lines 326–327).
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Predisposing factors | Am I able? | Participants attributed poor PA-related performance to CF related symptoms, such as breathlessness, fatigue and pain. | CF was not perceived as a barrier to PA per se. | |
“I can do it [PA], but not as good as other people…I get tired quicker than them, or out of breath more quicker. I can do it to a certain point, but then I have to stop.” (P3, pg13, lines 573–579).
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“…there’s nothing really…wrong with me I can still do it…I’m not stuck like at home or in hospital. I’m out, like able to do anything, really.” (P1, pg12, lines 515–525).
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For some this results in frustration, anger and boredom; | “I know just because I’ve got CF doesn’t mean I can’t do it [PA].” (P3, pg23, lines 1020–1021). | |||
“Well, it’s a bit annoying, because they’re all doing it, and I’m sat at the side, and it winds me up that I should be able to do it, but I just can’t.” (P3, pg13, lines 584–585).
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“… I have to do twice as much as my mate, to do what my mates do, so then when I can do what my mates are doing I just feel better, because I know that it doesn’t show that it’s affecting me, and I can keep up with my mates and just do all the exercise and everything.” (P6, pg20, lines 846–849).
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CF- related illness can render participants incapable of engaging in PA. | Perceptions of current well-being | |||
“…Like when I’m ill I feel like I can’t do anything. I’m sitting on the couch and watching TV, and I’m not doing much.” (P9, pg23, lines 1004–1005).
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“…’cos I am generally quite well, I can do it.” (P7, pg16, line 702).
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“I tend to have quite a high lung function, and I don’t really get ill a lot…” (P7, pg17, line 707).
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Is it worth it? | Some participants reported disliking the experience of pain, fatigue and breathlessness associated with PA; | All participants report enjoying PA. Enjoyment also appears to be inextricably linked to physical benefits gained through PA | ||
“(I dislike) The way you get tired and out of breath sometimes.” (P3, pg23, line 1025).
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“I like it [PA] because it helps my chest and stuff.” (P2, pg19, line 864)
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“That now and then it gives you the pains the next day. Like you’re dragging your legs up the stairs the next day.” (P9, pg35, lines 1517–1518).
| Participants also recognise health benefits associated with PA, both in the short and long term. | |||
“…it [PA] keeps you active and your lungs clear, and instead of just sitting in hospital or something.” (P1, pg14, lines 631–632).
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Engaging in PA becomes a normaliser; | ||||
“It’s just like you’re doing it because you can, and you want to. You kind of feel the same as everyone else for an hour and a half…” (p7, pg19, lines 803–804).
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Reinforcing factors | Parental support can generate a negative affect; | Family support and encouragement | ||
“I did a mile on the treadmill the other day, and Dad was like, “No, you’re going to do another one… (I feel like) I’m going to slap him. Push him off his bike. You do another mile!” (P7, pg12, lines 493–503).
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...my Mum always like, not makes me go, but if like I’m just too tired, I don’t want to, she’d be like, “Oh no, come on, let’s get out or something.” (P1, pg14, lines 641–643).
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Peer support | ||||
“…my friends who knock on for me, they are dead nice because they always ask if I’m ok if I’m out of breath and stuff when I’m out playing footy and stuff.” (P2, pg21, lines 942–944).
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“Like one of us wins a race or wins a game or something, I can go, “Oh yes, well, I’ve got CF”, and then it’s like pulling a CF card…I just find it funny, because they’re like, “Aaaaaaah! She’s done it again”…we have a laugh about it….” (P7, pg13–14, lines 565–574). | ||||
Significant coaches (conventional and novel, including PE teachers) influence | ||||
“Well, a mixture of everyone. There isn’t really anyone that influences me any more than someone else… Family, people in the CF team, my PE teachers.” (P4, pg11, lines 498–503). | ||||
The CF specialist physiotherapist was identified by participants (P2, 3 and 9) as the CF clinician who most encourages them to be physically active. Participants also perceive health-related information and advice to be trustworthy and reliable; | ||||
“I think that it’s good advice, and that I should take it.” (P1, pg11, line 482).
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Family facilitating activity (e.g. driving to sports clubs or engaging in family activities) | ||||
“My Mum or Dad would usually take me.” (P4, pg7, line 279).
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Phase 2
P | Age Group (Years) | Gender | Allocated device(s) | Compliance (Days worn) | Valid days included (≥10 h·day) | Mean wear time (h) |
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1 | ≤10 | Female | ActiGraph & Pedometer | 6 | 4 | 12.5 |
2 | > 10 | Male | ActiGraph & Fitbit | |||
3 | > 10 | Male | ActiGraph & Pedometer | |||
4 | > 10 | Male | GENEActiv | 7 | 6 | 16.3 |
5 | ≤10 | Female | ActiGraph & Pedometer | |||
6 | > 10 | Male | GENEActiv & Smartphone | |||
7 | > 10 | Female | GENEActiv | 6 | 6 | 13.3 |
8 | ≤10 | Male | GENEActiv & Fitbit | 7 | 4 | 23.3 |
9 | > 10 | Female | GENEActiv & Fitbit | 7 | 6 | 14.8 |
Phase 3
Participant interviews
Wear-ability
“The Fitbit was basically just like wearing a watch, but the ActiGraph kept getting in the way of when I’d be doing my PE and stuff” (P2, pg4, lines 145–146).“Well, I liked wearing the wrist one because I just liked it more than the other [ActiGraph]…it didn’t have anything for me to do on it, but it kept falling down at my waist and then making my waist really itchy and stuff.” (P2, pg1, lines 36–45).“because, do you know when you put it on the side, it hurts…it did hurt when I was doing some jogging” (P5, pg2–3, lines 62–70).
“It was just a bit thick, and it got in my way of doing general activities I do every day, and I had to be careful that I didn’t knock it and stuff like that, and it was quite thick. People noticed it a lot more, and was asking me about it, thinking it was a watch, and then when they actually saw it there was no watch… I was just a bit like, oh...” (P9, pg1, lines 27–30).
“it didn’t get in the way of me doing anything, or didn’t prevent me from doing anything either…” (P4, pg1, lines 35–36).
“They just asked what it was and what it did, and someone asked what the time was with the GENEActiv, and I had to say, “Oh no, it’s not a watch, it’s a blah, blah, blah…” (P7, pg4, lines 180–182).“They’d just ask for the time and I’d get my phone out, and they’d be like, “Why didn’t you just use your watch?” I’d be like, “because it’s this monitoring thing for the hospital”, or like my Mum said, “It’s broke.” (P6, pg5, lines 142–144).
“It was a lot more comfortable, the Fitbit. It looks ‘slicker’, it looks smarter than a big bulky thing.” (P8, pg2, lines 74–75).
“Well I usually carry my phone everywhere anyway, so it didn’t really affect me.” (P6, pg12, line 382).
Device feedback
“It was fun to know that I could look back and see how much I was doing…how many calories I’ve burned, how many steps I took, which was good.” (P4, pg1, lines 25–31).
“I suppose it taught me that what I was doing, I was doing it right. Like playing table tennis, I was actually doing the right amount of activity that I should be” (P4, pg13, lines 566–567).
“It was a bit confusing with too much going on, so it was hard to use.” (P7, pg13, line 581).
“I didn’t really dislike anything, because it was so simple, and showed you what you wanted to see.” (P6, pg12, lines 376–377).
Compliance
“I just think it feels like a natural thing, like say you’re getting ready for school in a morning, it’s like you get your t-shirt on, and you put it on basically, like natural.” (P1, pg4, lines 107–108).
“Well, I kept it next to where I sleep, so as soon as I woke up I’d put it on.” (P4, pg3, line 132).
“I didn’t forget with the Fitbit, but I could just keep it on all the time…I think I forgot with the GENEActiv because you have to take it off at night, so I might forget to put it on in the morning.” (P7, pg4, lines 148–151).
“Well, usually when we go on the field, we always just run after each other, like taking each other out…but I wouldn’t go too mad on doing that compared to what I normally do… If I take someone down, I won’t just damage whatever it is.” (P2, pg6, lines 255–258).“so you actually might hurt someone else, and you might hurt yourself in gymnastics” (P7, pg4, lines 140–141).
Summary
Health care professional interviews
Existing knowledge
“…the once a year test will prove what they do on that day, and it doesn’t tell us how they do their normal week, cope on a day-to-day week, so we don’t have any kind of measure about what they do, other than subjective, them telling us, “I do, and I’m fine”. You don’t have that information, so I suppose this just gives you over a period of time, if it’s a week or whatever, or two weeks if they were an in-patient, it would give us kind of better understanding of how they’re functioning on a day-to-day level.” (HCP-P, pg11, lines 411–416).
“I will ask them what they do, what sports they do, and how active they are, particularly if we’re having problems with weight gain or weight loss, so say for example you have somebody present to you who’s maybe lost a significant amount of weight, so part of that discussion will be about are you doing more activity, have you joined any other groups, are you doing more planned activity, trying to look at reasons why they might have lost weight. We don’t formally measure how much activity they’ve done and what the energy cost of that is…” (HCP-D, pg4, lines 128–140).
Perceived benefits
“I think, I suppose, trying to help young people to see that actually being physically inactive is potentially having an impact on their health and on their respiratory function, and helping them to see that if they can just increase their activity a bit, then that might have a positive impact on their respiratory health.” (HCP-D, pg5, lines 185–188).
“…I think we need a more consistent approach across the team, so it will help that. We can formalise more of our interventions with the patients, but we don’t know what those interventions should be, but we can be a bit more robust about it, a bit more sort of systematic, as opposed to just making it up as we go along, which is kind of what we do at the moment.” (HCP-C, pg9, lines 312–315).
“I think it would be maybe even a realism about what they do, or how little they do, or it reassures them that they’re doing enough, if they’re doing a lot. Certainly from our experience of monitoring when they do their nebulisers, they have been very very, surprised when they know what they’ve done, compared to what they think they’ve done. So I think that the effect might be, “Oh my God, I thought I was doing lots more than that”, or it might motivate them to do better, to improve.” (HCP-P, pg8, lines 293–298).
“…the ones we need to target are the ones who hate physical activity, who find gymnasiums an abomination. And we have a significant number of patients like that, and also quite a large proportion of our young women who are fourteen, fifteen, sixteen, exercise seems to be a non-cool thing for young girls particularly, to do. So those are the challenges we face. Now I’ve absolutely no hesitation to feel that our well-motivated patients will completely embrace this and will love it, and will get a lot out of it, and actually use it in their lives, and that’ll be great for them. But I have extreme anxieties how [sedentary patients] will not in any way be helped by this kind of monitoring. I don’t know. That might not be true. I don’t know what the answer is. If you monitor somebody and show them that the level of activity they’re doing is woeful, then that may motivate them to take a step forward themselves, and try and sort it out. I suspect not, but I don’t know.” (HCP-C, pg5, lines 151–161).
Acceptability
“we could very easily fit it into what we do. We have a very good relationship with our families, a respectful relationship, and we have the capacity within our care programme to sort of slot it in. We have plenty of time. We see them regularly in clinic every two to three months. We do annual review, obviously every year, and we see them in between times. Our families are very engaged, they’re very empowered, they want to do things for the better, on the whole, and they’re very keen to take on, to embrace new developments and new technologies.” (HCP-C, pg4, lines 132–137).
“I think generally everyone can appreciate the importance of exercise, but there is some definite variability amongst the team as to how we do that, and how important people feel it is.” (HCP-C, pg11, lines 394–396).
“I think we would really need to have families on board in partnership, and it would be something that they would need to see as a routine part of their CF care rather than just something that is a bit different and a bit special.” (HCP-C, pg4, lines 116–119).
“Well, I think that the relationship you have with your team, your CF team, is a very close relationship. It’s not always a relationship based on the greatest amount of honesty, and in those cases it’s just a bit tricky, but we’ve kind of dealt with a lot of these issues with a lot of our aerosol delivery devices, and are now able to incorporate data logging, so we have dealt with these issues with the i-neb, and we’ve been able to sort of sit down with the families and the young person in a very open way, and say...‘Just looking over the course of three months, we’ve seen you’ve gone from being a hundred per cent adherent to what you’re doing, to sort of just doing it once a day or whatever, and they’re going, “Yes, it’s a real struggle. Maybe we could go down to once a day”. So working in that open way has worked, I think, and we’ve been able to do some really good stuff in improving adherence in our patients with CF, and support them with treatments that they might be finding difficult or impossible.’” (HCP-C, pg10, lines 356–374).
“I think handling data is the key thing, and making sure that the data is readily available in a way that’s readily understood, both professionals and the family.” (HCP-D, pg11, lines 413–414).“I think we need to know what monitors and which are the best…We need to decide what information we need from them as to what benefit they’re going to be. So I think that’s one of the key issues, and I think they also need to be relatively affordable…And cleanable, and from that aspect, so that they can be wiped down.” (HCP-P, pg11, lines 394–398).
Summary
Phase 4
Individual priority ranking | Sum total | Collective ranking | |||||
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HCP-C (P5) | HCP-P (P3) | Researcher 1 (P4) | Researcher 2 (P2) | ||||
Part 1: Patient-Related Issues | |||||||
1 | Lifestyle based approach to physical activity | 5th | 1st | 2nd | 1st | 9 | 1st |
5 | Motivation is a key issue | 2nd | 2nd | 1st | 6th | 11 | 2nd |
6 | Perceived importance of physical activity and the data retrieved by the devices | 4th | 5th | 3rd | 3rd | 15 | 3rd |
3 | Experience of CF symptoms during physical activity | 6th | 3rd | 4th | 4th | 17 | 4th |
7 | Importance of fitness over physical activity | 3rd | 7th | 5th | 2nd | 17 | 5th |
2 | Decline of Physical activity | 1st | 4th | 7th | 8th | 20 | 6th |
4 | Importance of clinical versus “field” testing of physical activity levels | 7th | 8th | 6th | 5th | 26 | 7th |
8 | Structured vs. non-structured activity | 8th | 6th | 8th | 7th | 29 | 8th |
Part 2: Clinical Practice Issues | |||||||
2 | Education (for practitioners, parents/carers and children and young people) | 1st | 1st | 7th | 2nd | 11 | 1st |
4 | Importance of meaningful feedback | 5th | 5th | 3rd | 3rd | 16 | 2nd |
1 | Role of feedback provided by devices | 4th | 6th | 2nd | 5th | 17 | 3rd |
9 | Clinical barriers identified (cost, resources, time) | 10th | 2nd | 4th | 1st | 17 | 4th |
8 | Issues of compliance raised | 3rd | 4th | 5th | 7th | 19 | 5th |
6 | Sustainability of the physical activity engendered by the tool used in terms of: | 2nd | 7th | 9th | 6th | 24 | 6th |
7 | Importance of accruing 7 days worth of physical activity data: | 7th | 8th | 6th | 4th | 25 | 7th |
10 | Team message is important | 6th | 3rd | 8th | 8th | 25 | 8th |
3 | Testing vs. Monitoring | 8th | 9th | 1st | 9th | 27 | 9th |
5 | Distinction between the use of physical activity monitoring devices as a research tool vs. commercial tool | 9th | 10th | 10th | 10th | 39 | 10th |
Part 3: Research Issues | |||||||
1 | Cost | 5th | 1st | 1st | 1st | 8 | 1st |
4 | Children and young people involvement required to inform the research process | 1st | 2nd | 3rd | 4th | 10 | 2nd |
3 | Type of data produced by research vs. commercial devices | 2nd | 3rd | 2nd | 5th | 12 | 3rd |
5 | Literacy and understanding | 3rd | 4th | 5th | 3rd | 15 | 4th |
2 | Issues of compliance | 4th | N/A | 4th | 2nd | N/A | N/A |
Patient-related issues
“Really important is to continue ongoing education on the exercise with the patients and the families, throughout all ages and stages of disease progression, with discussion concerning expectations of the patient, the family and the therapist, and to reinforce that exercise and activity as a lifestyle choice rather than prescription, in order to improve compliance.” (P3, pg3, lines 92–96) .
“You might get that instant feedback, but you don’t know how to interpret that information correctly. That could have a negative impact on your motivation, or a positive impact, or no impact.” (P4, pg18, lines 691–693).
Clinical practice issues
“In terms of the education, I think that kind of counselling, it doesn’t have to be a psychologist. It can be, that type of support can be offered in different ways through different roles, through training, through educating parents. It’s not necessarily about parachuting a specific practitioner in. I guess it’s looking for that opportunity, capacity, and the willingness to sort of take on board some of that, in the same way that exercise professionals who work in gyms, they’re not exercise psychologists, but they are very much at the front end of applying principles of exercise psychology in order to make sure that the people they address, whether it’s the cardiac rehab plan or reducing obesity, whatever it is, they’re sort of applying the technique.” (P2, pg19, lines 698–706).
Research issues
“We need some funding to be able to do this.” (P2, pg23, line 855).
“…they are very articulate and able to talk about these devices, and therefore in any future research we should make sure that it’s not just research on children, it’s research with, and alongside, and involve them in the design.” (P2, pg24, lines 896–898).